Family doctors cautious about new guidelines to prevent heart disease

Domino, Silk, Saver and Adler favor lifestyle changes over more drugs

By Sandra Gray

UMass Medical School Communications

January 10, 2014

Family doctors at UMass Medical School are discussing how they will use new guidelines from the American Heart Association to help patients reduce their risk of heart disease. In addition to indisputable recommendations for healthy lifestyle changes and weight management, the guidelines include expanded parameters for reducing unhealthy LDL cholesterol that will lead more people to take statin drugs than ever before.

But whether the benefits of statins outweigh the risks of side effects for individuals at lower risk for heart disease, and how best to assess that risk, are being extensively debated.

Frank Domino, MD, and other UMMS family physicians applaud the guidelines’ move away from specific low density lipoprotein (LDL or “bad” cholesterol) numbers as goals for treating high cholesterol, focusing instead on which patients should take statins based upon their individual demographics and cardiovascular risk.

But they question the recommendation that adults whose risk of a heart attack in the next ten years is 7.5 percent or higher should be prescribed ‘moderate’ doses of statins for primary prevention.

“For those whose risk is greater than 7.5 percent but have no congenital heart disease or diabetes, a patient-centered, informed consent discussion about the pros and cons of drug treatment is needed,” Domino said. “I do not tell my patients what to do, but rather give them a peek at their options.”

He does this by using one of the available risk calculators to compare what an individual’s risk of having a heart attack in the next ten years is without medication versus what their risk will be with an assumed 20 percent reduction in LDL achieved by taking a statin.

“Comparing these two risk estimates will help patients understand their potential benefits from medication, and allow them an opportunity to make an informed choice about whether or not to initiate statin therapy,” he explained. “When I do this, most patients realize the actual benefit is very small unless they have known heart disease.”

Potential side effects of statins, including severe muscle pain, memory loss and liver inflammation, are especially concerning to family doctors who oversee patients’ overall health and well-being.

“The new lipid guidelines will result by some estimations in one billion people needing statins. In fact by some risk calculators, any man over 70 needs to be on a statin!” said Hugh Silk, MD, clinical associate professor of family medicine & community health. “We will need to show caution and treat each person as an individual and not merely by protocol lest we end up with some part of that billion people with complications from medications, and a huge population who feel that health issues can be solved with a pill rather than a change in lifestyle.”

Developed specifically to support the guidelines, the AHA’s new Pooled Risk Cohort Equations calculator joins similar tools including the Framingham Risk Calculator and the Atherosclerosis Risk in Communities calculator that primary care physicians and cardiologists have long used. Domino is among those who have not adopted the new risk calculator developed by the AHA Task Force to specifically support the guidelines because they believe it overstates risk.

“The Pooled Risk Cohort Equations risk calculator is very controversial and reportedly overestimates risk substantially in the crucial range around the magic 7.5 percent line,” said Barry Saver, MD, MPH, associate professor of family medicine & community health. “The new guidelines are a big step forward, but we should be cautious about magic lines drawn on continuous risk distributions and spurious precision of risk calculators.”

“Our patients will have different preferences based on their own values, and we should help them choose a path concordant with their own values and preferences,” agreed Ron Adler, MD, assistant professor of family medicine & community health. “For years, I have been using these calculators to help patients understand the factors that determine their risk. By modifying input variables one can often easily demonstrate that controlling blood pressure or quitting smoking may have a greater or equivalent impact on cardiovascular disease risk as reducing cholesterol. Remember, everyone should be counseled regarding low-fat, low-cholesterol diets and exercise!”

“Until the controversy over which risk calculator to use and whether the cutoff of a 7.5 percent in low-risk individuals is appropriate, clinicians should treat all patients with patient-centered counseling about appropriate dietary changes, smoking cessation, and aerobic exercise,” Domino concluded.